Wang’s Chinese Herbs 王氏医药
CALIFORNIA ALTERNATIVE AND COMPLEMENTARY HEALTH CARE NOTICE AND CONSENT FORM
The California Legislature enacted California Senate Bill SB-577 that affirms the right of citizens to obtain Alternative and Complementary Health Care from practitioners other than licensed Physicians and Surgeons or other licensed health professions.
In Paragraph 1 of SB 577 the Legislature made a Finding that:
"Based upon a comprehensive report by the National Institute of Medicine and other studies, including a study published by the New England Journal of Medicine, it is evident that millions of Californians, perhaps more than five million, are presently receiving a substantial volume of health care services from complementary and alternative health care practitioners. Those studies further indicate that individuals utilizing complementary and alternative health care services cut across a wide variety of age, ethnic, socioeconomic, and other demographic categories."..... Thus, the Legislature wanted to recognize Alternative and Complementary Health Care and provide a framework of guidelines and notices.
Pursuant to this Act of the Legislature, Alternative and Complementary Health Care Practitioners must inform clients that they are not Physicians and Surgeons or allied licensed practitioners and that for a western medical diagnosis and treatment, including, but not limited to, prescription drugs, surgery and the treatment of fractures, lacerations and abrasions, the clients must see an MD, Physician or Surgeon. The notice must also state the nature of the Alternative and Complementary Health Care practice that is being provided.
The theory of Traditional Chinese Medicine believes that Health & balanced Qi is essential for human’s health and it is achieved through a harmonious relationship with nature, meaningful interactions with others. All physical or emotional transformations of the body depend on the correct and balanced function of the Qi.
Wang’s Chinese Herbs (王氏医药), which is a DBA of kingxo LLC (registered in U. S. Food and Drug Administration), is operated by Qingcai Wang only. He is not a licensed Physician, Surgeon or Acupuncturist. The herbal pouch attached to the acupuncture points of body will improve the conditions of body. All herbs are to be applied or attached to outside of the body and they are prohibited to be taken by mouth under any circumstances.
I (patient) understand that rather than western medical advice or treatment, I am seeking alternative treatment in the form of Traditional Chinese Medicine. Under no circumstances, should any suggestions be taken as a diagnosis or direction against the advice of a licensed physical or medical care professional.
I confirm that I am seeking Alternative and Complementary Health Care and advice in natural health only, and if I desire a diagnosis, treatment or acupuncture from Western Medicine, I must consult a licensed Physician, Surgeon or Acupuncturist. I acknowledge that Qingcai Wang or Wang’s Chinese Herbs (王氏医药）is not a licensed medical doctor, acupuncturist or medical institution in the State of California.
I hereby accept full responsibility for any actions taken by myself concerning any herbs with Qingcai Wang and Wang’s Chinese Herbs (王氏医药). I hereby release the above named from any liability resulting in any possible damages or loss during our association. I acknowledge that I have read and understood all that is disclosed here.
Name (Print): ____________ Signature: _________ Date: __________
Sex: _______ Age: ____ Occupation: _______ Phone: ______